“There is a much broader awareness of what optical practice can deliver”

So, how has the profession changed over the past few years – and what will the coming months and years bring? Ahead of Whittington’s departure, OT caught up with him to find out.

You started at LOCSU in November 2016 – with everything that has happened since, does that seem like a very long time ago?

So much has happened over the last two years, in every walk of life. That has almost distorted time a little bit. So, the last two years in some respects have dragged incredibly, but in other respects, it has almost been like a time reset. Although it is five years, it almost feels like three years and two years: what was before, and what is after. Where COVID-19 started was a break with what had happened before, and everything that's happened since is because of it. It’s a strange feeling.

In terms of LOCSU supporting the profession, how have the last couple years progressed?

Because LOCSU is there to support the LOCs, the question is more, “What has it been like for the LOCs, and therefore what support have we had to do as LOCSU?” It’s obviously been a challenge for the LOCs, but they have really risen to it. They’ve stepped up and been that local support network for their members within their localities. They’ve done a lot in terms of bringing the sector together and communicating information. In the first phase of the pandemic, a number of them coordinated personal protective equipment (PPE) rollouts and sourcing of PPE on behalf of practices.

CUES was done, start to finish, in three weeks, and it showed what can be done when we’re under pressure

Our job has been to support the LOCs in that role, which is what we did in terms of things like setting up the PPE shop. Where LOCSU really did come to the fore, along with everybody else in the sector, was when sight testing stopped during first lockdown. We recognised quickly that there was still going to be a need for patients to be able to access primary care. We had to have a mechanism for doing that. That was where the COVID Urgent Eyecare Service (CUES) came in. Our normal process for defining a service – getting the pathways and processes written and signed off – was quite a long process. CUES was done, start to finish, in three weeks, and it showed what can be done when we’re under pressure.

From a LOCSU point of view, getting CUES done was really important. That service was always there to be the COVID-19 Urgent Eyecare Service, but it was also there to provide the bedrock for what we knew was going to come after it.

I think everybody realised that if you stop providing clinical services across the board, we're going to feel the pain of that once things come back to normal. There were always going to be a whole host of backlogs. We had to have something that provided a service that could be delivered throughout COVID-19, but that also provided a framework and foundations for what could come afterwards. That will ultimately be Optometry First. That’s where I think we were able to provide a lot of value.

It hasn’t been easy for LOCSU, but it has been harder for everybody else. We were here to support. We were not the ones seeing the patients on the front line

In terms of pure LOCSU issues, we created a levy holiday for the first four months of COVID-19, which meant the LOCs didn't have to pay. That, I think, was useful.

Since then, it has been about trying to bring together LOCs and individuals to be able to deliver the services that we’re going to need as we move out of the COVID-19 phase and into the recovery phase, and ultimately into the service transformation phase. It hasn’t been easy for LOCSU, but it has been harder for everybody else. We were there to support. We were not the ones seeing the patients on the front line. We were not the people who were trying to work out whether they were seeing someone with COVID-19 or without COVID-19. If you think back to the first phase, that was a real consideration. Our job is to support. I think we did that well, and I think it was recognised, and I hope that’s what we’ll be able to continue to do.

Community and support of LOCs must have become increasingly important over the last couple of years, alongside the further realisation that practices and networks are part of a whole, sharing the care of patients…

Absolutely. LOCs are statutory organisations, but that’s their strength. They are there to provide and support locally. That is the bedrock of an LOC. It’s the one founding principle. It is always local practitioners talking about local issues, whether or not you are somebody who owns one practice in that area, or somebody who works for a multiple and works across country – you are still representing your locality in your LOC. That is absolutely vital; it is the strength of the LOC.

LOCs are well-placed to promote our profession, but they’re also well-placed to make links so we can start to talk about primary care more holistically

That played out through COVID-19, and I think going forward it is going to be even more important. As we move from Clinical Commissioning Groups (CCHs) to Integrated Care Systems (ICSs) and Integrated Care Boards (ICBs), LOCs are still going to have to be that local voice in whatever the commissioning delivery structure is. That's more important than ever.

It’s that recognition that primary care is more than just GPs. It’s us, it’s dentistry, it’s pharmacy, and it’s general practice, working together as a primary care service. LOCs are well-placed to promote our profession, but they’re also well-placed to make links so we can start to talk about primary care more holistically.

The bit within the changes that I think has been drowned out has been us being primary care networks. I think it’s something we need to look to cultivate, because that primary care network is your local delivery network. That's what it’s there for. It's important that we are able to help to define a primary care network as a genuine primary care network as opposed to a GP network. That will be delivered locally, and that message and the reality will be delivered by the LOCs.

It's so important that people know they don’t need to go to their GP for everything. It's a difficult task to relay that to the public though, isn't it?

That’s the missing piece of most transformation programmes. We talk about service transformation, pathway transformation; contract transformation. That’s all important, but the activity that really drives transformation is patient behaviour and patient change. And it’s a hard task.

It’s about understanding that the most important thing is that patients receive the most appropriate care in the most appropriate location. That does not always need to be hospital

Take glaucoma as an example. If we get to the point where we can co-manage glaucoma in practice, and there’s no reason why we should not do that, if you’re somebody who is used to receiving glaucoma care and has received that kind of care for the last decade in hospital, suddenly being told that actually you don’t need to go to hospital and you can go to your practice – that’s an interesting message to try and get across. Some people will see that as, “Why is my care not important enough to see the consultant?” But it's not about that. It’s about understanding that the most important thing is that patients receive the most appropriate care in the most appropriate location. That does not always need to be hospital.

That is the key driver of transformation. You can produce the best service and the best system in the world, but if people don't use it, it’s rubbish. You have to drive patient behaviour as well, and that is challenging.

How do you think LOCs can go about getting that message out?

LOCs’ outward facing role is going to be into the ICSs and into the NHS delivery organisations, to promote what it is that primary care can do. That's step one. Once that is established, and once the structures are formed and we’re embedded within them, an LOC could have a role in starting to promote outwardly to the patient groups about what optometry can provide.

It's a dual role. It’s outward one way and outward the other way, whilst also being the glue that sticks everything together locally. It’s a complex task, and it’s really important. It’s something that LOCSU, in partnership with everybody else, has got to spend the next months preparing people to be able to deliver. July is the formal transfer from CCGs to ICSs, but then there’s the work that sits behind it, so we understand exactly how things are going to operate. That’s where LOCs need to be.

Do you think LOCSU is in a different place now, compared to how it was when you started?

There has been a whole host of change. LOCSU was responsible for preparing the tools to deliver extended services, like Minor Eye Condition Services (MECS) and glaucoma catch-up services. If you look back to where it was five years ago to where it is now, there’s has been a proliferation of those services being delivered across the country. There is a much broader awareness of what optical practice can deliver. I think that needs to continue, and that’s where Optometry First will drive through.

The support that we provide on the ground is different. We had commissioning leads when I started, which were much more about the mechanics of commissioning, whereas we’ve now got optical leads. They’re much more holistic. They’re still talking about services, but they’re also doing work with LOCs around succession planning, and how LOCs can set themselves up to be able to answer challenges in the future, but also to be self-sustaining. That's a big change.

When I arrived, there were something like 130 CCGs in England. We’re going to have about 40 ICSs. The commissioning landscape has consolidated and it’s right, in my view, that the delivery landscape also consolidates. The strength of a local primary eye care company is, as it always has been, that it can provide services locally. The strength of a consolidated company, whether that’s two companies coming together or 100 companies coming together, is that it can still deliver that local service because the LOC is still very much involved. But if a commissioned organisation wants to commission across a broader geographical scope, it is able to do that as well. That was, and still is, the drive. Certainly, primary eye care company consolidation has accelerated.

LOCs have proven that they're able to deliver these services, and that's the best way of driving further gains

The work that we did through COVID-19, and what will become the Optometry First service, is absolutely vital. That has come about because LOCs and the members and practices within those LOCs have proven that they're able to deliver these services, and that's the best way of driving further gains. So, that's changed significantly.

The work that we do jointly across the country has shifted too. Just before COVID-19 we set up a series of regional forums. That was to bring together LOCs in a particular NHS England region, so they could start to talk about areas of commonality and areas of difference. It came off the back of the LOC consultation we did in 2019. They were really useful through COVID-19. They provide a good bedrock for LOCs to start to work together and to collaborate and understand what the issues are in neighbouring areas within the same NHS England region, but with slightly different approaches to delivery. When you look back on it, quite a lot has changed in the last five years. It’s a totally different landscape.

Any highlights from your time at LOCSU?

I’m really proud of the way the LOCs have come together and worked together and started support networks. Whilst there’s quite a lot still to be done, if we look at the proliferation of the services over the last five years, I’m pleased that that there is now an understanding, I think in every CCG and in most commissioners’ minds, primary care optometry can do more. I think that's good.

There is now an understanding, I think in every CCG and in most commissioners’ minds, that primary care optometry can do more

In terms of COVID-19, I think the way in which the LOC community came together to support, coupled with the fact that we were able to get CUES over the line as quickly as we could, meant that we’ve got a firm foundation for what's going to come. We were able to show, as an LOC community, exactly what primary care optometry is, what it can do, and what its potential is. The absolute key thing now is not to lose that – it's to build on it and to continue to deliver more and more within primary care in order to aid both recovery and transformation.

The backlogs are enormous. It's going to take time to clear them. But I have a view that I've held all through my time at LOCSU, which is that hospital services are the endpoints of a pathway, but that pathway exists in front of the hospital.

You have to look at the pathways end-to-end. If a person arrives in hospital, either they arrive as an emergency or they arrive in a slightly more controlled way, maybe into an outpatient appointment or as a referral for a particular procedure. When they hit the hospital there’s a whole host of processes that have taken place already to get to that point. When we’re looking at things like outpatient recovery, you can’t focus entirely on the hospital activity. You have to focus on what’s come before it as well, because it’s by improving the pathway end-to-end that you ultimately get the improvement at the end.

We were able to show, as an LOC community, exactly what primary care optometry is, what it can do, and what its potential is. The absolute key thing now is not to lose that

Take for example MECS, CUES, what will become Optometry First – the front end of those services is always about asking whether a patient can be safely managed within primary care, without the need to access either community or hospital care. If that is the case, then that’s a patient who maybe would have been referred, who now is not. They’re not going to need to have hospital input. It’s about working in partnership across the whole of the pathway, in accord with all stakeholders, to ensure that it works appropriately and in a streamlined way, end-to-end. If you get that bit right, that makes that hospital recovery, where a lot of the focus is, a little bit easier.

Whether we’re talking about primary care reform, community care reform, acute care reform – it’s all just three parts of exactly the same pathway. You have to take them together.